Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
| WORK SETTINGS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Acute Care – Adult |
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| Clinic – Adult |
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| SNF/LTAC/Subacute |
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| Hospice / Palliative Care |
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| Acute/Long Term Care – Pediatrics |
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| Clinic – Pediatrics |
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| PRESSURE ULCERS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Assessment |
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| Staging |
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| Prevention/ Risk Assessment Tools – Adult |
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| Prevention/ Risk Assessment Tools -Pediatrics |
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| Support Surface Selection |
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| NEUROPATHIC ULCERS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Assessment |
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| Management |
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| VENOUS STASIS ULCERS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Assessment |
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| Management |
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| PERIPHERAL ARTERIAL ULCERS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Assessment |
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| Ankle Brachial Index |
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| Management |
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| OTHER WOUNDS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Fistulae – Pouching / Skin Care |
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| Skin Care/ Management of Drains |
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| WOUND DEBRIDEMENT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Autolytic |
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| Enzymatic |
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| Mechanical |
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| Sharp |
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| DRESSINGS/ TREATMENTS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Hydrogels |
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| Hydrocolloids |
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| Silver Products |
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| Foams |
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| Alginates |
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| Vacuum Assisted Closure |
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| Growth Factors |
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| Skin Substitutes |
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| Hyperbaric Oxygen Therapy |
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| Wound Cultures |
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| Electrical Stimulation |
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| Enzymatic Debriding Agents |
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| Mist Therapy |
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| COLOSTOMY / ILEOSTOMY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Ostomy Equipment Selection |
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| Continence Skin Care Management |
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| Loop with Rod Stoma |
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| End Stoma |
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| Mucous Fistula |
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| Double Barrel Stoma |
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| Irrigation |
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| Ileal Lavage |
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| CONTINENT ILEOSTOMY | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Knock pouch |
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| Pelvic Pouch |
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| UROSTOMY / CONTINENT | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Catherization for C&S |
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| Knock Pouch |
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| Neobladder |
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| CONTINENCE THERAPEUTIC DEVICES | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Vaginal Cones |
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| Penile Clamps |
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| Male External Catheters |
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| Internal Urethral Inserts |
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| Catheters –Mgmt & Self Care Teaching |
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| Magnetic Therapy |
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| Urinary Incontinence Program |
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| Fecal Incontinence Program |
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| BURNS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Burn Management |
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| PROFESSIONAL KNOWLEDGE AND SKILLS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| National Patient Safety Goals/ Core Measures |
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| Patient Family Teaching |
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| Age Specific/Population Based Care |
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| Isolation Precautions |
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| Infection Precautions |
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| Pain assessment & Management |
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| Interpretation & Communication of Lab Values |
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| EMR |
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| EPIC |
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| Cerner |
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| Eclipsys |
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| McKesson |
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| Other Computerized System |
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| Computerized Physician Order Entry |
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| Bar coding for Medication |
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| Culture |
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| OTHER / MISC. | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Pain Management Assessment of Pain Levels without intervention |
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| Pain Management Response Assessment with Intervention |
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| Experience: Charge Duty |
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| Experience: Preceptor |
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| AGE SPECIFIC CARE | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Infant (Birth to 1 year) |
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| Toddler (1-3 years) |
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| Pre-school (3-6 years) |
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| School Age (6-12 years) |
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| Adolescent (12-18 years) |
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| Young Adult (18-30 years) |
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| Mature Adult (30-60 years) |
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| Elderly (>60 years) |
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